Requirements & Forms

We provide benefits for certain services, drugs and supplies only if approval is obtained in advance. This ensures the procedures are diagnostically appropriate, medically necessary and cost effective. 

Please consider the following before marking a Prior Approval Request as “urgent”:

  • Marking a request as “urgent” does not guarantee immediate review; state guidelines permit us up to 48 hours to review a request marked as “urgent” (or one that is automatically treated as urgent under state rules).
  • The most appropriate time to mark a request as “urgent” will be in situations involving urgently needed care (as defined by state regulations).
  • We must respond to all prior approval requests within two business days, whether they are marked “urgent” or not.
  • Please remember to submit requests before the member’s appointment.
  • Please avoid submitting requests on a Friday unless necessary.
  • Please ensure a request for prior approval is complete and contains required clinical information, as this will expedite the process.

BlueCard Members:  To look up out-of-area member's prior approval/pre-notification/pre-certification/pre-service requirements, please use the Medical Policy Router.

Medical Policies: developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease.

Acuity Connect: Portal designed to allow providers the ability to view and submit prior approval and pre-notification requests electronically.  The portal allows providers to see the status and documentation associated with the authorization submitted. Accessible by logging into the secure Provider Resource Center.


Prior Approval Lists

To determine what prior approval requirements apply to a patient/member, refer to the table below.

Members OfPrior Approval Requirements
  • Blue Cross and Blue Shield of Vermont
  • The Vermont Health Plan
  • New England Health Plan (NEHP)**/ Access Blue New England (ABNE)**
  • State of Vermont
  • University of Vermont Medical Center

Federal Employee Program

Only require Prior Approval on certain services, which are based on medical necessity. For a complete quote of benefit information, please contact The Federal Employee Program at (800) 328-0365.

**NOTE:  Prior Approvals for members with NEHP/ABNE should only be sent to Blue Cross and Blue Shield of Vermont if the member has selected a primary care provider located in the State of Vermont.  If the member has selected a PCP in any other state the local Blue Cross and Blue Shield  Plan’s prior approval guidelines will apply and requests need to be submitted directly to that Plan.

Prior Approval Form

Use the State of Vermont Uniform Medical Prior Authorization Form for all prior approval and pre-service requests, except radiology and pharmacy (details below). 


Please note: 

  • Although the form is titled “State of Vermont” use if for all member types, not just State of Vermont employees.
     
  • The fax number for completed prior approval forms is (866) 387-7914
     

Facts and Tips on the State of Vermont Uniform Medical Prior Authorization Form

 

Some services also require a completed worksheet

These services require both a Uniform Prior Authorization Form and a completed worksheet:
 

Radiology & Pharmacy Services Prior Approval

  • Radiology services (elective) - CT, CTA, MRI, MRA, MRS & PET scans use AIM Provider Portal
  • Pharmacy Services:

Questions or need help? Contact provider service at (800) 924-3494.